Service de cancérologie-radiothérapie, hôpital Saint-Louis, 1, avenue Claude-Vellefeaux, 75475 Paris, France.
Clin Res Hepatol Gastroenterol. 2011 Jan;35(1):17-22. doi: 10.1016/j.gcb.2010.07.017.
Many randomised studies have now well established the role of radiotherapy (RT) in rectal cancer: it decreases the rate of local relapse and improves survival for stage II and III. The benefit of RT remains even in case of total mesorectum excision. Preoperative strategy has a better tolerance and is more efficient than post-operative RT. Two schedules have been widely used: an hypofractionated (5 × 5 Gy) and a normofractionated (45-50 Gy by fractions of 1.8-2 Gy) schedule. Both have advantages and drawbacks. Patients with locally advanced tumours or low-lying cancer must benefit from a protracted schedule, which increases down staging and the number of sphincter-preserving surgery. Combined chemoradiotherapy with 5FU or capecitabine enhances local control without a clear benefit in overall survival or disease-free survival. Adjunction of oxaliplatin does not improve the pathological response rate significantly. Results with cetuximab are still disappointing. Bevacizumab seems to increase widely the radiation response, but more data are needed to confirm these preliminary results. With this modern approach, the rate of local relapse is lower than 10%; the main issue is now the occurrence of distant relapses in 25-30% of the patients. Neo-adjuvant chemotherapy (CT) seems the better way to address this issue, because post-operative CT could be done properly in only 50% of the patients. Large prospective trials using neo-adjuvant CT with or without targeted therapies must be designed taking distant relapses and overall survival as main end-points.
现在已经有许多随机研究充分证实了放疗（RT）在直肠癌中的作用：它降低了局部复发率，并改善了 II 期和 III 期患者的生存率。即使在完全直肠系膜切除的情况下，RT 的益处仍然存在。术前策略的耐受性更好，比术后 RT 更有效。已经广泛使用了两种方案：一种是低分割（5×5 Gy），另一种是常规分割（45-50 Gy，1.8-2 Gy 分）。两者都有优点和缺点。局部晚期肿瘤或低位肿瘤患者必须受益于延长治疗方案，这可以提高降期和保留括约肌手术的数量。5FU 或卡培他滨联合放化疗可增强局部控制，但对总生存或无病生存没有明显益处。奥沙利铂的附加并不能显著提高病理反应率。西妥昔单抗的结果仍然令人失望。贝伐单抗似乎广泛增加了放疗反应，但需要更多的数据来证实这些初步结果。采用这种现代方法，局部复发率低于 10%；现在的主要问题是 25-30%的患者发生远处转移。新辅助化疗（CT）似乎是解决这个问题的更好方法，因为只有 50%的患者可以进行术后 CT。必须设计使用新辅助 CT 联合或不联合靶向治疗的大型前瞻性试验，以远处转移和总生存为主要终点。
